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Meaningful Participation Requirements

Maintenance of Certification at BCM

For questions, please contact: BCM MOC Program

In order for a physician's or physician assistant's participation in a QI activity/project to qualify for Maintenance of Certification (MOC) Part 4 credit consideration, evidence of their participation in the activity must be met and submitted in accordance with stated ABMS Portfolio Program™ Meaningful Participation Requirements, as described below.

Additionally, their QI activity/project must meet stated ABMS Portfolio Program™ QI Activity Requirements.


The American Board of Medical Specialties Portfolio Program™ (ABMS Portfolio Program™) operates through a national network of health care organizations that serve as ABMS Portfolio Program Sponsors and with participating ABMS Member Boards and the National Commission on Certification of Physician Assistants (NCCPA) to award credit to eligible physicians and physician assistants.

Baylor College of Medicine (BCM) is an approved and recognized ABMS Portfolio Program Sponsor (Program Sponsor). This achievement was coordinated through the BCM Institute for Continuing Professional Development in Quality Improvement and Patient Safety (I-QIPS), which oversees all Program Sponsor responsibilities, as conducted through the BCM Maintenance of Certification Program (BCM MOC Program), operated under the I-QIPS.

As a Program Sponsor, BCM works directly with the ABMS Portfolio Program™ to help BCM and BCM-affiliated physicians/PAs earn MOC Part 4 credit/MOC points for their work in eligible QI efforts that promote the College's quality and safety aims. This is done through the BCM MOC Program, where physicians/PAs can request credit consideration via streamlined and facilitated processes. In coordination with the physician/PA, the BCM MOC Program prepares and submits on their behalf the necessary paperwork for credit consideration through the ABMS Portfolio Program™, ultimately resulting in less paperwork and more time for physicians and PAs to focus on delivering quality care to their patients.


Updated: June 2021

Participation Eligibility Criteria

To be eligible for consideration of MOC Part 4 credit/points through the ABMS Portfolio Program™, the physician/PA should meet at least one (1) of the following criteria:

  • Provides direct or consultative care to patients.
  • Oversees clinical care delivery.
  • Has an organizational leadership role in quality improvement or patient safety.
  • Serves as a quality improvement coach, trainer, or student/resident QI advisor.
Meaningful Participation Requirements

With respect to their QI effort, the physician/PA must fulfill all three (3) of the following requirements for meaningful participation:

  1. The QI effort must provide clear benefit to the physician/PA’s patients and/or (for any QI leaders in non-caregiving roles) be directly related to the physician/PA’s clinical practice.
  2. The physician/PA must be actively involved in the QI effort by participating in at least three (3) of the following four required project activities, as described:
    1. Project Design:
      • Identify and/or acknowledge a gap(s) in outcomes or in care delivery;
      • Identify and/or review data related to the gap(s); AND
      • Select one:
        • Identify or acknowledge appropriate intervention(s) designed to improve the gap(s).
        • Participate in the planning and selection of intervention(s) designed to improve the gap(s).

    2. Implementation of Interventions:
      • Select one:
        • Implement intervention(s) for a timeframe appropriate to addressing the gap(s).
        • Monitor and manage implementation of intervention(s) for a timeframe appropriate to addressing the gap(s).

    3. Data Collection/Analysis:
      • Review post-intervention data related to the gap(s).
    4. Active participation in project meetings
  3. The physician/PA must reflect* on project outcomes to determine whether the intervention(s) resulted in any improvement. If no improvement occurred after a given intervention, the physician/PA is asked to include in their reflection why no improvement occurred.

*Upon their reflection of outcomes, the physician/PA is required to attest to meeting the above requirements. The designated Physician/PA Attestation & Reflection Form required for the respective QI effort being submitted for credit must be signed by the physician/PA seeking credit, and, unless otherwise instructed, co-signed by the Project Leader (or by a Supervisor, if the physician/PA seeking credit is also the Project Leader).